RC-4-18-1082 CanceledMiami Shores Village
Building Department APR 25 2018
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 ^ 7 I -
Tel: (305)795-2204 Fax:(305) 756-8972
�N�hJji�l� : (305) 762�949
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' (\,e� F�BC 201',A �u
BUILDING Ytlpl o cc,l w/ (�C_ 10-20'43Master Permit No. tILC� I - IW Z
PERMIT APPLICATION
BUILDING ❑ ELECTRIC ❑ ROOFING
Sub Permit
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING [-]MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 9 ;) 3 of q to sT
City:
Miami Shores
County: Miami Dade Zip: •�
/ 3R
Folio/Parcel(
1 ( - 3 7GG ON
- 24?M Is the Building Historically Designated: Yes
NO
Occupancy Type:
Load:
Construction Type: Flood Zone: BFE:
FIFE:
OWNER: Name (Fee Simple Titleholde f (p 61 (,rp,+-1 ba-, A,SG7& r,,�oAvhone#:
Arlriracc• a �Ci.S • %Q �- �°/ 1(0
�J � N� �t {-� we
� t' •tom
City: tip) t t�..-. • S`� 0'4 - - State: -� Zip: •�
Tenant/Lessee Name: Phone#:
Email:
'i� �l(� 991,
� CONTRACTOR: Company Name: Y/9vC/oa ax e.- � c vz Phone#: 781, 3`l� 4
Address: 560o 5� 127 -Av�, LA14' 2-403,
City: Mia,,,: State: Zip: 331 E33
Qualifier Name: Lponn,clo figyeyy4 Phone#: 713t, 5
State Certification or Registration #: CMG / S / Z l/y9 Certificate of Competency #:
DESIGNER: Architect/Engineer: masood /"e61i'll')i Phone#: �15Cf-�4Fi -�tl��
Address: City: State:Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑
Addition
❑ Alteration
❑ New [Repair/Replace ❑ Demolition
Description of Work:
-tu
Specify color of color thru
Submittal Fee
Permit Fee $
CCF
MCC $
Scanning Fee $ Radon Fee $ a, C5�5 DBPR $ �— Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $s Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
Zip
Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC.....
OWNER'S AFFIDAVIT: 1 certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNE, EFORE RECORDING
YOUR NOTICE OF COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value ex eed ng $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law broc ure ill be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of comment mot must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In th a ce of such posted notice, the
inspection will not be appr ed d a reinspection fee will be charged.
or AGENT
The foregoing instrument
^was
'acknowledged before me this
ko
day of Mom" . 20 M by
qYC%f{ =,who is personally known to
me or who has produced
NOTARY
MARIA C. MONTES
WCOMMISSION # FF 99459B
EXPIRES: June 5, 2020
rind Thiu Notary Public Undevrtere
Print: �•�• LN.. •-��
Seal:
APPROVED BY
rli
(RevisedO2/24/2014)
as
CONTRACTOR
The foregoing instrument
rwas
sracknowledged before me this
A!:)
< day of 20 KD by
/
t—ftxan O 4. e-&a �vho is eersonally known to
me or who has produced as
,wr!e MARIAC.MONTES
NOTARY PUB MY COMMISSION# FF 994596
EXPIRES: June S. 2020
V rl ,'�;'o';ij?P••' Byr�tl Thru Notary Public Underwriters
Print:
Seal:
Plans Examiner
Structural Review
Zoning
Clerk